Provider Demographics
NPI:1366709768
Name:KISAKA, JILL MARIE (RDH)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:KISAKA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:222 TONGASS DR
Mailing Address - Street 2:ATTN: JILL KISAKA IN DENTAL
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-9416
Mailing Address - Country:US
Mailing Address - Phone:907-966-2411
Mailing Address - Fax:907-966-8663
Practice Address - Street 1:222 TONGASS DR
Practice Address - Street 2:ATTN: JILL KISAKA IN DENTAL
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-9416
Practice Address - Country:US
Practice Address - Phone:907-966-2411
Practice Address - Fax:907-966-8663
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2027124Q00000X
WADH 60100153124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist